Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus

Negative pressure wound therapy following excision of pilonidal sinus disease: A retrospective review

AIM

There is no agreed definitive surgical treatment for pilonidal sinus disease (PSD) with several techniques in use with varying success. Negative pressure wound therapy (NPWT) is used to accelerate wound healing but literature in the context of PSD remains sparse. The aim of this study was to evaluate outcomes in patients with PSD treated by a standardised technique of complete surgical excision followed by the application of NPWT.

METHODS

A retrospective observational cohort study of all patients with PSD managed by complete surgical excision followed by application of NPWT was performed over a five year period. The primary endpoints were PSD recurrence and failed wound healing.

RESULTS

Sixty-one patients underwent treatment during the study period. There was 100% compliance with NPWT. All patients' wounds healed successfully, with the median time to healing being 28 days. One patient (1.6%) developed recurrent PSD and required further surgery. Two patients (3.3%) developed postoperative wound infections. Five patients, who had been managed previously by other operative approaches and subsequently developed recurrence, were successfully managed by this technique. Most patients (52.4%) were managed as a day case procedure.

CONCLUSIONS

Surgery for PSD should have low recurrence rates, prompt wound healing, minimal complications, short inpatient lengths of stay and be tolerated by the patient. Our results demonstrate that our technique meets these criteria. To our knowledge, this study contains the largest number of patients with PSD managed by excision and NPWT in the literature.

Patient Satisfaction After the Cleft-Lift Procedure

Introduction Although Pilonidal disease is rarely life-threatening, it is a painful and potentially embarrassing condition that if left untreated or treated poorly, can disrupt a patient's ability to enjoy life, function at work, develop relationships, or attend school or the military. There are several different approaches to this problem which include non-surgical measures, minimally invasive surgery, excisional surgery, or flap surgery. This article relates the experience with a surgical practice that offers only the cleft lift procedure and describes the degree of patient satisfaction with the operation. Materials and Methods Seven hundred and fifty-one patients were treated between 2011 and 2021. Surveys were sent out to these patients by email after at least eight weeks had elapsed from surgery. The study was closed once 500 responses were obtained. Statistical analysis was performed to determine if patients who had undergone previous pilonidal surgery (salvage group) had different opinions than the patients who did not (primary group). Results Of the 500 respondents, 494 (98.8%) were "extremely satisfied" or "satisfied" with their procedure; 444 (88.8%) felt that the recovery process was "very easy" or "easy" and only 56 (11.2%) felt that it was "difficult but worth it" or "really hard". Four hundred and one (80.2%) felt that the activity restrictions were "minimal, I was back to normal activity very quickly"; 438 (89.4%) felt that the scar looked "really good" or answered, "it's fine, not an issue for me. I'm just glad to be done with this". Whether the patients had previous failed surgery or not, the vast majority (78.2% and 79.6% respectively) felt that the cleft lift was an appropriate first operation for pilonidal disease; and statistical analysis failed to show any significant differences in opinions between the primary and salvage groups on any of the questions. The few patients who ultimately were dissatisfied with the procedure were unhappy with the cosmetic appearance of the scar and shape of the buttocks. By comparing the demographic characteristics of the respondents to the entire cohort, we found them to be similar groups, suggesting that the respondents were representative of the group as a whole. Conclusion A correctly performed cleft lift operation provides a solution that is very well accepted by patients, specifically in regard to recovery time, appearance, appropriateness, and overall satisfaction.

Excision and tension-free primary closure of pilonidal disease

Objectives

This study aimed to estimate simple excision and tension free primary closure and to study its effectiveness in terms of operating and healing time, duration of hospital stay, degree of post operation complications, and rate of recurrence.

Material and Methods

This is study included 78 patients, of whom 71 were (91%) males and 7 (9%) females, who underwent excision and tension free closure. The procedure was based on bilateral side flaps, which were released and dissected 2-3 cm from the edge of the wound. Patient's age, gender, body mass index, wound healing, operation, drain removal, length of hospital stay, and complications and recurrence were analysed.

Results

The study involved 78 patients, 71 (91%) males and 7 (9%) females. Median age of the patients was 28.5 years. Mean operation time was 44.6 minutes . Sixty-one patients (78.2%) had full primary healing without any complication. No one had hematoma or seroma, but five (6.4%) cases had a minor wound infection and three (3.8%) obese patients developed recurrence. Mean length of hospital stay was 2.5 days , most patients went back to their work within 3 weeks. Median follow-up period was in a 26.2 weak range (1-51.4 weak). Five (6.41%) cases had wound infection and three (3.85%) developed recurrence.

Conclusion

Excision and tension free primary closure were found to be simple procedures associated with lower rates of wound infection, shorter hospital stay, lower recurrence, early wound recovery and short period of being absent from work. Surgery can be easily performed and preferred for cases of non-recurrent pilonidal sinus and cyst.

Impact of geography and surgical approach on recurrence in global pilonidal sinus disease

Pilonidal sinus disease (PSD) is increasing globally. A recent meta-analysis and merged-data analysis showed that recurrence rates in PSD depend essentially on follow-up time and specific surgical procedures. However, the global distribution of surgical approaches and respective recurrence rates have never been studied in PSD. We aimed at studying the impact of geographic distribution of surgical approaches to treat PSD and subsequent geography-specific recurrence rates. We searched relevant databases as described previously. Recurrence rates were then associated with reported follow-up times and geographic origin. We simulated individual patients to enable analogy across data. Globally, recurrence rates range from 0.3% for Limberg/Dufourmentel approaches (95% CI 0.2–0.4) and flaps (95% CI 0.1–0.5) and up to 6.3% for incision (95% CI 3.2–9.3) at 12 months. Recurrence rates range from 0.3% for Karydakis/Bascom approaches (95% CI 0.0–0.8) up to 67.2% for incision (95% CI 7.5–100) in the USA, and 0.0% for primary asymmetric closure in Germany (95% CI 0.0–0.0). Our analysis shows that recurrence rates in PSD not only depend on therapeutic approaches and follow-up time but also on geography. Primary asymmetric closure and various flap techniques remain superior regardless of the geographical region. Some approaches have extraordinarily good outcomes in specific countries.

Limberg flap in management of pilonidal sinus disease: systematic review and a local experience

OBJECTIVES

To review published evidence of Limberg flap (LF) use in pilonidal sinus disease (PSD). We also included our local experience of LF.

METHODS

Medline and Embase database were searched for the words 'pilonidal, sinus, Limberg, flap'. Non-English articles and those not-related to our scope of search were omitted. We included a retrospective study of patients underwent LF in our district hospital. Data including length of hospital stay, post-operative complications and recurrence were collected.

RESULTS

Literature review revealed 68 studies (22 case series, 35 comparative studies, nine RCTs and two meta-analyses). Recurrence rate was 0-7.4% in case series. Recurrence rate in comparative studies was 0-8.3%, compared to 4-37.7% for primary closure and 0-11% for Karydakis flap. RCTs showed that LF or its modification is superior to primary closure, with comparable results to Karydakis flap. About 26 patients included in the cohort study (16 male, average age 27 years). Six patients presented with recurrent disease. Post-operative length of hospital stay was four to seven days. Post-operative complication rate was 11.5% - [two partial wound dehiscence, one wound infection]. Recurrence rate was 7.7%. Average follow-up was 18 months.

CONCLUSIONS

Limberg flap presents a safe and effective method that can be offered for patients with primary or recurrent PSD.

Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3-0.9%) 12 months and 1.8% (95%CI 1.1-2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1-0.3%) 12 months and 0.6% (95%CI 0.5-0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3-82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.

A new surgical approach for pilonidal sinus disease: "de-epithelialization technique''

Objective

In the treatment of pilonidal sinus disease different approaches are used such as conservative treatment and fasciocutaneous rotation flap. The aim of this study was to evaluate the efficacy of "de-epithelialization technique" as a new approach in pilonidal sinus disease treatment.

Material and Methods

Forty pilonidal sinus disease patients treated with de-epithelialization method were evaluated retrospectively. Patient age, gender, body mass index, wound healing time, visual analog scale scores, operation times, hospital stay duration, drain removal time, cosmetic satisfaction rates, complications, and recurrence rates were evaluated.

Results

The numbers of male and female patients in this study were 39 and 1, respectively. The median age of the patients was 25 years and the mean BMI was 26.6. The mean operating time was 43 min, and all patients were discharged 5 h after the operation. Wound healing time varied from 10 to 20 days. Median follow-up period was 9 months (4-17 months). One patient with high body mass index suffered from partial wound separation. No other complications such as infections and fluid collections (hematoma and seromas) were observed. Maximum cosmetic satisfaction rate was 90% (n=36), and no patient had a recurrence during the follow-up period.

Conclusion

"De-epithelialization" may be considered as a complementary and/or alternative approach to other surgical techniques such as primary closure, rhomboid excision, and Limberg flap in the treatment of pilonidal sinus disease, with acceptable cosmesis and recurrence rates.

Anatomic Effect of Classical Limberg Plastic Surgery Procedure in the Sacro-Coccygeal Region for Pilonidal Sinus Disease: A Pilot Study

Sacro-coccygeal pilonidal sinus disease is a frequent surgical problem. Some authors assign the low recurrence rates of the Limberg flap to the flattening or elevation of the natal cleft. Numerous authors describe a flattening or elevation of the natal cleft as a result of a Limberg flap that originated from the gluteal region. However, thus far, these have not been quantified. The aim of our study was to quantify the flattening or elevation of the natal cleft. In the context of our study on the Limberg flap plasty with a homogenous group of 12 male patients, we measured the depth of the rima ani after the excision, and we also measured the thickness of the Limberg flap. The median thickness of the rima ani at excision was 3.35 cm [interquartile range (IQR): 2.70; 4.18]. The median thickness of the Limberg flap was 4.85 cm (IQR: 3.90; 5.18). The thickness of the rima ani after excision was statistically significantly less compared with the thickness of the Limberg flap (P = 0.002). In our study, we showed the elevation of the crena ani with statistical significance by performing the Limberg flap for the treatment of sacro-coccygeal pilonidal sinus disease, leading to a flattening of the sacro-coccygeal region. Because a deep crena ani is a factor in the pathogenesis of pilonidal sinus, the flattening of the sacro-coccygeal region with a Limberg flap plasty, as reported in countless publications, may explain the low recurrence rates.

[Pilonidal sinus: Secondary wound closure vs. Limberg flap : Cost and satisfaction analysis]

BACKGROUND

After excision of a pilonidal sinus, several treatment options are possible, but no gold standard has been established. A literature review revealed no study comparing the costs and time off work after either secondary wound closure or treatment with a Limberg transposition flap. The aim of this study was to focus on these aspects by analysing the patients treated at the KlinikumStadtSoest.

METHOD

Sixty patients with pilonidal sinus after excision were treated either by secondary wound closure or Limberg transposition flap at the KlinikumStadtSoest between 2011 and 2012. The authors analysed retrospectively the patients' demographics, cost, and satisfaction with both techniques and compared them.

RESULTS

For secondary wound closure (group 1) 19 out of 31 patients and for Limberg transposition flap (group 2) 21 out of 29 met the inclusion criteria. Time off work following the final surgery (group 1: 69 day vs. group 2: 30 days, p = 0.046) and the number of dressing changes (group 1: 107 times vs. group 2: 16 times, p = 0.000) were significantly lower in the group of Limberg transposition flap (group 2) as well as the associated costs. The surgery-related costs were lower when treated by secondary wound closure.

DISCUSSION

Plastic reconstruction with Limberg transposition flap (group 2) provides a chance to reduce the period of incapacity for work due to a shorter treatment period. With that said, patients should nonetheless be offered both techniques as the current literature does not reveal a clear benefit for either procedure.

Recurrent pilonidal sinus: lay open or flap closure, does it differ?

Treatment options of pilonidal sinus, which has high recurrence rates, is still controversial. In this study, we aimed to analyze for possible factors affecting recurrence. Forty-one patients with recurrent pilonidal sinus were included in this study. Of them, 33 were male and 9 were female (mean age, 24.9 years; age range, 16-42). Factors (i.e., risk factors) were detected in 32 patients. Excision-secondary healing and lay open was performed on 30 of the patients admitted with recurrence. Excision and flap closure was applied on 11 patients. Our recurrence rate was 9.7%. The recurrence rate of our study is compatible with the literature. Comparative studies are needed to determine the appropriate method to decrease recurrence rate.

The evaluation of a modified Dufourmentel flap after S-type excision for pilonidal sinus disease

PURPOSE

The use of an S-type oblique excision with a bilateral gluteus maximus advancement flap has recently been described for the surgical treatment of sacrococcygeal pilonidal sinus (SPS). Its use in wide lesions has been limited due to the need for a full-thickness flap. We describe the use of an S-type oblique incision together with the Dufourmentel flap in wide lesions.

METHOD

Twenty-one patients were treated using a technique including an S-shaped oblique excision of the sinus tract and a broad-pedicled full-thickness flap resembling a Dufourmentel flap to close the defect.

RESULTS

Of the 21 patients, 19 (90.5%) were male and 2 (9.5%) were female. Their mean age was 24.0 ± 6.1 (range 15-36) years. The mean follow-up period was 14.0 ± 5.8 (range 6-23) months. The postoperative complication rate was 4.8% (one patient), and recurrence was seen in one patient (4.8%). The mean return-to-work time was 13.5 ± 1.9 (range 10-18) days. None of the patients reported dissatisfaction with the cosmetic results.

CONCLUSIONS

This new technique achieved low morbidity and recurrence rates. We anticipate that this will become an important technique in the surgical treatment of SPS if the observed success is confirmed by randomized prospective trials.